1
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Auner S, Hillebrand C, Boehm PM, Boecker J, Koren D, Schwarz S, Kovacs Z, Murakoezy G, Fischer G, Aigner C, Hoetzenecker K, Jaksch P, Benazzo A. Impact of Transient and Persistent Donor-Specific Antibodies in Lung Transplantation. Transpl Int 2024; 37:12774. [PMID: 38779355 PMCID: PMC11110840 DOI: 10.3389/ti.2024.12774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/15/2024] [Indexed: 05/25/2024]
Abstract
Lung transplantation (LuTx) is an established treatment for patients with end-stage lung diseases, however, outcomes are limited by acute and chronic rejection. One aspect that has received increasing attention is the role of the host's humoral alloresponse, particularly the formation of de novo donor-specific antibodies (dnDSAs). The aim of this study was to investigate the clinical significance of transient and persistent dnDSAs and to understand their impact on outcomes after LuTx. A retrospective analysis was conducted using DSA screening data from LuTx recipients obtained at the Medical University of Vienna between February 2016 and March 2021. Of the 405 LuTx recipients analyzed, 205 patients developed dnDSA during the follow-up period. Among these, 167 (81%) had transient dnDSA and 38 (19%) persistent dnDSA. Persistent but not transient dnDSAs were associated with chronic lung allograft dysfunction (CLAD) and antibody-mediated rejection (AMR) (p < 0.001 and p = 0.006, respectively). CLAD-free survival rates for persistent dnDSAs at 1-, 3-, and 5-year post-transplantation were significantly lower than for transient dnDSAs (89%, 59%, 56% vs. 91%, 79%, 77%; p = 0.004). Temporal dynamics of dnDSAs after LuTx have a substantial effect on patient outcomes. This study underlines that the persistence of dnDSAs poses a significant risk to graft and patient survival.
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Affiliation(s)
- S. Auner
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - C. Hillebrand
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - P. M. Boehm
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - J. Boecker
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - D. Koren
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - S. Schwarz
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Z. Kovacs
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - G. Murakoezy
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - G. Fischer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - C. Aigner
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - K. Hoetzenecker
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - P. Jaksch
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - A. Benazzo
- Vienna Lung Transplant Program, Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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2
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Mineura K, Tanaka S, Goda Y, Terada Y, Yoshizawa A, Umemura K, Sato A, Yamada Y, Yutaka Y, Ohsumi A, Nakajima D, Hamaji M, Mennju T, Kreisel D, Date H. Fibrotic progression from acute cellular rejection is dependent on secondary lymphoid organs in a mouse model of chronic lung allograft dysfunction. Am J Transplant 2024:S1600-6135(24)00162-X. [PMID: 38403187 DOI: 10.1016/j.ajt.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 02/27/2024]
Abstract
Chronic lung allograft dysfunction (CLAD) remains one of the major limitations to long-term survival after lung transplantation. We modified a murine model of CLAD and transplanted left lungs from BALB/c donors into B6 recipients that were treated with intermittent cyclosporine and methylprednisolone postoperatively. In this model, the lung allograft developed acute cellular rejection on day 15 which, by day 30 after transplantation, progressed to severe pleural and peribronchovascular fibrosis, reminiscent of changes observed in restrictive allograft syndrome. Lung transplantation into splenectomized B6 alymphoplastic (aly/aly) or splenectomized B6 lymphotoxin-β receptor-deficient mice demonstrated that recipient secondary lymphoid organs, such as spleen and lymph nodes, are necessary for progression from acute cellular rejection to allograft fibrosis in this model. Our work uncovered a critical role for recipient secondary lymphoid organs in the development of CLAD after pulmonary transplantation and may provide mechanistic insights into the pathogenesis of this complication.
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Affiliation(s)
- Katsutaka Mineura
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Satona Tanaka
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Yasufumi Goda
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuriko Terada
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Akihiko Yoshizawa
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | - Keisuke Umemura
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Atsuyasu Sato
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshito Yamada
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yojiro Yutaka
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiro Ohsumi
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Daisuke Nakajima
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masatsugu Hamaji
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toshi Mennju
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA; Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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3
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Knight SR, O’Callaghan JM. Transplant Trial Watch. Transpl Int 2024; 37:12711. [PMID: 38389709 PMCID: PMC10883077 DOI: 10.3389/ti.2024.12711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024]
Affiliation(s)
- Simon R. Knight
- Oxford Transplant Centre, Churchill Hospital, Oxford, United Kingdom
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - John M. O’Callaghan
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
- University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
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4
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Bansal S, Rahman M, Ravichandran R, Canez J, Fleming T, Mohanakumar T. Extracellular Vesicles in Transplantation: Friend or Foe. Transplantation 2024; 108:374-385. [PMID: 37482627 DOI: 10.1097/tp.0000000000004693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
The long-term function of transplanted organs, even under immunosuppression, is hindered by rejection, especially chronic rejection. Chronic rejection occurs more frequently after lung transplantation, termed chronic lung allograft dysfunction (CLAD), than after transplantation of other solid organs. Pulmonary infection is a known risk factor for CLAD, as transplanted lungs are constantly exposed to the external environment; however, the mechanisms by which respiratory infections lead to CLAD are poorly understood. The role of extracellular vesicles (EVs) in transplantation remains largely unknown. Current evidence suggests that EVs released from transplanted organs can serve as friend and foe. EVs carry not only major histocompatibility complex antigens but also tissue-restricted self-antigens and various transcription factors, costimulatory molecules, and microRNAs capable of regulating alloimmune responses. EVs play an important role in antigen presentation by direct, indirect, and semidirect pathways in which CD8 and CD4 cells can be activated. During viral infections, exosomes (small EVs <200 nm in diameter) can express viral antigens and regulate immune responses. Circulating exosomes may also be a viable biomarker for other diseases and rejection after organ transplantation. Bioengineering the surface of exosomes has been proposed as a tool for targeted delivery of drugs and personalized medicine. This review focuses on recent studies demonstrating the role of EVs with a focus on exosomes and their dual role (immune activation or tolerance induction) after organ transplantation, more specifically, lung transplantation.
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Affiliation(s)
- Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
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5
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Sullivan HC, Gandhi MJ, Gaitonde S, Narasimhan R, Gendzekhadze K, Pandey S, Roby RK, Maha GC, Kaur H, Schiller JJ, McDowell J, Smith M, Liu C, Morris GP. Seventy-five years of service: an overview of the College of American Pathologists' proficiency testing program in histocompatibility and identity testing. Front Genet 2023; 14:1331169. [PMID: 38169613 PMCID: PMC10758433 DOI: 10.3389/fgene.2023.1331169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/20/2023] [Indexed: 01/05/2024] Open
Abstract
The Histocompatibility and Identity Testing Committee offers an overview of the College of American Pathologists' (CAP) Proficiency Testing (PT) program, commemorating its significant 75th anniversary in 2024. The CAP PT program has undergone significant growth and evolution over the years, ultimately achieving Centers for Medicare and Medicaid Services approval. In 1979, CAP's partnership with the American Association for Clinical Histocompatibility Testing marked a pivotal moment, leading to the creation of the first proficiency testing survey in 1980. This laid the foundation for various PT programs managed by the CAP Histocompatibility and Identity Testing Committee, including HLA antibody testing, HLA molecular typing, engraftment monitoring, parentage/relationship testing, HLA disease associations and drug risk, and HLA-B27 typing. Each program's distinctive considerations, grading methodologies, and future prospects are detailed here, highlighting the continual evolution of histocompatibility and identity testing PT to support emerging technologies and evolving laboratory practices in the field.
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Affiliation(s)
- H. Cliff Sullivan
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, United States
| | - Manish J. Gandhi
- Mayo Clinic, Department of Laboratory Medicine and Pathology, Rochester, MN, United States
| | - Sujata Gaitonde
- Department of Pathology, University of Illinois Chicago, Chicago, IL, United States
| | - Ramya Narasimhan
- Boston University Medical Center, Department of Pathology and Laboratory Medicine, Boston, MA, United States
| | | | - Soumya Pandey
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Rhonda K. Roby
- Alameda County Sheriff’s Office Crime Laboratory, Oakland, CA, United States
| | | | - Harmeet Kaur
- Cuyahoga County Regional Forensic Science Lab, Cleveland, OH, United States
| | | | - Julie McDowell
- College of American Pathologist (CAP), Chicago, IL, United States
| | - Maria Smith
- College of American Pathologist (CAP), Chicago, IL, United States
| | - Chang Liu
- Washington University in St. Louis, Department of Pathology and Immunology, Saint Louis, MO, United States
| | - Gerald P. Morris
- Department of Pathology, Univeristy of California San Diego, San Diego, CA, United States
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6
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Subburayalu J. Immune surveillance and humoral immune responses in kidney transplantation - A look back at T follicular helper cells. Front Immunol 2023; 14:1114842. [PMID: 37503334 PMCID: PMC10368994 DOI: 10.3389/fimmu.2023.1114842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 06/22/2023] [Indexed: 07/29/2023] Open
Abstract
T follicular helper cells comprise a specialized, heterogeneous subset of immune-competent T helper cells capable of influencing B cell responses in lymphoid tissues. In physiology, for example in response to microbial challenges or vaccination, this interaction chiefly results in the production of protecting antibodies and humoral memory. In the context of kidney transplantation, however, immune surveillance provided by T follicular helper cells can take a life of its own despite matching of human leukocyte antigens and employing the latest immunosuppressive regiments. This puts kidney transplant recipients at risk of subclinical and clinical rejection episodes with a potential risk for allograft loss. In this review, the current understanding of immune surveillance provided by T follicular helper cells is briefly described in physiological responses to contrast those pathological responses observed after kidney transplantation. Sensitization of T follicular helper cells with the subsequent emergence of detectable donor-specific human leukocyte antigen antibodies, non-human leukocyte antigen antibodies their implication for kidney transplantation and lessons learnt from other transplantation "settings" with special attention to antibody-mediated rejection will be addressed.
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Affiliation(s)
- Julien Subburayalu
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Center for Regenerative Therapies (CRTD), Technische Universität Dresden, Dresden, Germany
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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7
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Kleid L, Walter J, Vorstandlechner M, Schneider CP, Michel S, Kneidinger N, Irlbeck M, Wichmann C, Möhnle P, Humpe A, Kauke T, Dick A. Predictive value of molecular matching tools for the development of donor specific HLA-antibodies in patients undergoing lung transplantation. HLA 2023. [PMID: 37068792 DOI: 10.1111/tan.15068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/21/2023] [Accepted: 04/06/2023] [Indexed: 04/19/2023]
Abstract
Molecular matching is a new approach for virtual histocompatibility testing in organ transplantation. The aim of our study was to analyze whether the risk for de novo donor-specific HLA antibodies (dnDSA) after lung transplantation (LTX) can be predicted by molecular matching algorithms (MMA) and their combination. In this retrospective study we included 183 patients undergoing LTX at our center from 2012-2020. We monitored dnDSA development for 1 year. Eplet mismatches (epMM) using HLAMatchmaker were calculated and highly immunogenic eplets based on their ElliPro scores were identified. PIRCHE-II scores were calculated using PIRCHE-II algorithm (5- and 11-loci). We compared epMM and PIRCHE-II scores between patients with and without dnDSA using t-test and used ROC-curves to determine optimal cut-off values to categorize patients into four groups. We used logistic regression with AIC to compare the predictive value of PIRCHE-II, epMM, and their combination. In total 28.4% of patients developed dnDSA (n = 52), 12.5% class I dnDSA (n = 23), 24.6% class II dnDSA (n = 45), and 8.7% both class II and II dnDSA (n = 16). Mean epMMs (p-value = 0.005), mean highly immunogenic epMMs (p-value = 0.003), and PIRCHE-II (11-loci) (p = 0.01) were higher in patients with compared to without class II dnDSA. Patients with highly immunogenic epMMs above 30.5 and PIRCHE-II 11-loci above 560.0 were more likely to develop dnDSA (31.1% vs. 14.8%, p-value = 0.03). The logistic regression model including the grouping variable showed the best predictive value. MMA can support clinicians to identify patients at higher or lower risk for developing class II dnDSA and might be helpful tools for immunological risk assessment in LTX patients.
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Affiliation(s)
- Lisa Kleid
- Laboratory for Immunogenetics, Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
- Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
| | - Julia Walter
- Division of Thoracic Surgery, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center Munich (CPC-M), German Center for Lung Research (DZL), Munich, Germany
- Department of Medicine V, University Hospital, LMU Munich, Munich, Germany
| | | | - Christian P Schneider
- Division of Thoracic Surgery, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center Munich (CPC-M), German Center for Lung Research (DZL), Munich, Germany
| | - Sebastian Michel
- Comprehensive Pneumology Center Munich (CPC-M), German Center for Lung Research (DZL), Munich, Germany
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Nikolaus Kneidinger
- Comprehensive Pneumology Center Munich (CPC-M), German Center for Lung Research (DZL), Munich, Germany
- Department of Medicine V, University Hospital, LMU Munich, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Christian Wichmann
- Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
| | - Patrick Möhnle
- Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
| | - Andreas Humpe
- Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
| | - Teresa Kauke
- Division of Thoracic Surgery, University Hospital, LMU Munich, Munich, Germany
- Transplantation Center, University Hospital, LMU Munich, Munich, Germany
| | - Andrea Dick
- Laboratory for Immunogenetics, Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
- Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, LMU Munich, Munich, Germany
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8
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Ennis SL, Olsen N, Tong WWY, Goddard L, Watson N, Weston L, Iqbal A, Patel P, Malouf MA, Plit ML, Darley DR. Specific HLA-DQ risk epitope mismatches are associated with chronic lung allograft dysfunction after lung transplantation. Am J Transplant 2023:S1600-6135(23)00401-X. [PMID: 37054889 DOI: 10.1016/j.ajt.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/01/2023] [Indexed: 04/15/2023]
Abstract
A high-risk epitope mismatch (REM) (found in DQA1*05 + DQB1*02/DQB1*03:01) is associated with de novo donor-specific antibodies (dn-DSA) after lung transplant (LTx). Chronic lung allograft dysfunction (CLAD) remains a barrier to LTx survival. The aims of this study were to measure the association between DQ REM and risk of CLAD and death after LTx. A retrospective analysis of LTx recipients at a single centre was conducted between Jan-2014 and Apr-2019. Molecular typing at HLA-DQA/DBQ identified DQ REM. Multivariable competing risk and Cox regression models were used to measure the association between DQ REM and time-to-CLAD and time-to-death. DQ REM was detected in 96/268(35.8%) and DQ REM dn-DSA detected in 34/96(35.4%). CLAD occurred in 78(29.1%) and 98(36.6%) recipients died during follow-up. When analysed as a baseline predictor, DQ REM status was associated with CLAD (SHR 2.19 95%CI 1.40-3.43; p=0.001). After adjustment for time dependent variables, dn-DQ-REM DSA (SHR 2.43 95%CI 1.10-5.38; p=0.029) and A-grade rejection score (SHR 1.22 95%CI 1.11-1.35; p=<0.001), but not DQ REM status was associated with CLAD. DQ REM was not associated with death (HR 1.18 95%CI 0.72-1.93; p=0.51). Classification of DQ REM may identify patients at risk of poor outcomes and should be incorporated into clinical decision-making.
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Affiliation(s)
- Samantha Louse Ennis
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia
| | - Nicholas Olsen
- Stats Central, Mark Wainwright Analytical Centre, UNSW Sydney, Sydney, Australia
| | - Winnie W Y Tong
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Louise Goddard
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Narelle Watson
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Lyanne Weston
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Ayesha Iqbal
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Purvesh Patel
- NSW Transplantation and Immunogenetics Services, Australian Red Cross Lifeblood
| | - Monique Anne Malouf
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Marshall L Plit
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - David Ross Darley
- Department of Lung Transplantation, St Vincent's Hospital Darlinghurst, Sydney, Australia; UNSW Medicine, St Vincent's Clinical School, University of New South Wales, Sydney, Australia.
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9
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Keller M, Yang S, Ponor L, Bon A, Cochrane A, Philogene M, Bush E, Shah P, Mathew J, Brown AW, Kong H, Charya A, Luikart H, Nathan SD, Khush KK, Jang M, Agbor-Enoh S. Preemptive treatment of de novo donor-specific antibodies in lung transplant patients reduces subsequent risk of chronic lung allograft dysfunction or death. Am J Transplant 2023; 23:559-564. [PMID: 36732088 PMCID: PMC10079558 DOI: 10.1016/j.ajt.2022.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 01/20/2023]
Abstract
The development of donor-specific antibodies after lung transplantation is associated with downstream acute cellular rejection, antibody-mediated rejection (AMR), chronic lung allograft dysfunction (CLAD), or death. It is unknown whether preemptive (early) treatment of de novo donor-specific antibodies (dnDSAs), in the absence of clinical signs and symptoms of allograft dysfunction, reduces the risk of subsequent CLAD or death. We performed a multicenter, retrospective cohort study to determine if early treatment of dnDSAs in lung transplant patients reduces the risk of the composite endpoint of CLAD or death. In the cohort of 445 patients, 145 patients developed dnDSAs posttransplant. Thirty patients received early targeted treatment for dnDSAs in the absence of clinical signs and symptoms of AMR. Early treatment of dnDSAs was associated with a decreased risk of CLAD or death (hazard ratio, 0.36; 95% confidence interval, 0.17-0.76; P < .01). Deferring treatment until the development of clinical AMR was associated with an increased risk of CLAD or death (hazard ratio, 3.00; 95% confidence interval, 1.46-6.18; P < .01). This study suggests that early, preemptive treatment of donor-specific antibodies in lung transplant patients may reduce the subsequent risk of CLAD or death.
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Affiliation(s)
- Michael Keller
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Laboratory of Transplantation Genomics, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland, USA; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA; Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Song Yang
- Office of Biostatistics Research, National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
| | - Lucia Ponor
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Ann Bon
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | - Mary Philogene
- Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA; Johns Hopkins Immunogenetics Laboratory, Baltimore, Maryland, USA
| | - Errol Bush
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Pali Shah
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joby Mathew
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Anne W Brown
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Hyesik Kong
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Laboratory of Transplantation Genomics, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland, USA; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA
| | - Ananth Charya
- Division of Pulmonary and Critical Care Medicine, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Helen Luikart
- Genome Transplant Genomics (GTD), Stanford University School of Medicine, Palo Alto, California, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA; Department of Pathology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Steven D Nathan
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Kiran K Khush
- Genome Transplant Genomics (GTD), Stanford University School of Medicine, Palo Alto, California, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Moon Jang
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Laboratory of Transplantation Genomics, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland, USA; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA
| | - Sean Agbor-Enoh
- Laboratory of Applied Precision Omics (APO),National Heart,Lung and Blood Institute (NHLBI),National Institutes of Health,Bethesda,Maryland,USA; Laboratory of Transplantation Genomics, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, Maryland, USA; Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland, USA; Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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10
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Lunardi F, Abbrescia DI, Vedovelli L, Pezzuto F, Fortarezza F, Comacchio GM, Guzzardo V, Ferrigno P, Loy M, Giraudo C, Fraia AS, Faccioli E, Braccioni F, Cozzi E, Gregori D, Verleden GM, Calabrese F, Schena FP, Rea F. Molecular Profiling of Tissue Samples with Chronic Rejection from Patients with Chronic Lung Allograft Dysfunction: A Pilot Study in Cystic Fibrosis Patients. Biomolecules 2023; 13:biom13010097. [PMID: 36671482 PMCID: PMC9856133 DOI: 10.3390/biom13010097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/26/2022] [Accepted: 12/29/2022] [Indexed: 01/06/2023] Open
Abstract
Chronic rejection (CR) is the main culprit for reduced survival and quality of life in patients undergoing lung transplantation (Ltx). High-throughput approaches have been used to unveil the molecular pathways of CR, mainly in the blood and/or in bronchoalveolar lavage. We hypothesized that a distinct molecular signature characterizes the biopsies of recipients with clinically confirmed histological signs of CR. Eighteen cystic fibrosis patients were included in the study and RNA sequencing was performed in 35 scheduled transbronchial biopsies (TBBs): 5 with acute cellular rejection, 9 with CR, and 13 without any sign of post-LTx complication at the time of biopsy; 8 donor lung samples were used as controls. Three networks with 33, 26, and 36 differentially expressed genes (DEGs) were found in TBBs with CR. Among these, seven genes were common to the identified pathways and possibly linked to CR and five of them (LCN2, CCL11, CX3CL1, CXCL12, MUC4) were confirmed by real-time PCR. Immunohistochemistry was significant for LCN2 and MUC4. This study identified a typical gene expression pattern in TBBs with histological signs of CR and the LCN2 gene appeared to play a central role. Thus, it could be crucial in CR pathophysiology.
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Affiliation(s)
- Francesca Lunardi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | | | - Luca Vedovelli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Federica Pezzuto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Francesco Fortarezza
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Giovanni Maria Comacchio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | | | - Pia Ferrigno
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Monica Loy
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Chiara Giraudo
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Anna Sara Fraia
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Eleonora Faccioli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Fausto Braccioni
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Emanuele Cozzi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Dario Gregori
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Geert M. Verleden
- Department of Respiratory Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Fiorella Calabrese
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-049-8272268
| | | | - Federico Rea
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
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11
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Stanjek-Cichoracka A, Ochman M, Chełmecka E, Hrapkowicz T. Assessment of Anti-Human Leukocyte Antigen (HLA)-Antibody-Dependent Humoral Response in Patients before and after Lung Transplantation. Medicina (Kaunas) 2022; 58. [PMID: 36556973 DOI: 10.3390/medicina58121771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/18/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
Background and Objectives: Testing for anti-human leukocyte antigen (HLA) antibodies both before and after transplantation is of fundamental significance for the success of lung transplantation. The aim of this study was the evaluation of anti-HLA immunization of patients before and after lung transplant who were subjected to qualification and transplantation. Materials and Methods: Prior to the transplantation, patients were examined for the presence of IgG class anti-HLA antibodies (anti-human leukocyte antigen), the so-called panel-reactive antibodies (PRA), using the flow cytometry method. After the transplantation, the class and specificity of anti-HLA antibodies (also IgG) were determined using Luminex. Results: In the group examined, the PRA results ranged from 0.1% to 66.4%. Low (30%) and average (30-80%) immunization was found in only 9.7% of the group examined. Presence of class I anti-HLA antibodies with MFI (mean fluorescence intensity) greater than 1000 was found in 42.7% of the patients examined, while class II anti-HLA antibodies were found in 38.4%. Immunization levels before and after the transplantation were compared. In 10.87% of patients, DSA antibodies (donor-specific antibodies) with MFI of over 1000 were found. Conclusions: It seems that it is possible to confirm the correlation between pre- and post-transplantation immunization with the use of the two presented methods of determining IgG class anti-HLA antibodies by increasing the size of the group studied and conducting a long-term observation thereof.
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12
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Bos S, Milross L, Filby AJ, Vos R, Fisher AJ. Immune processes in the pathogenesis of chronic lung allograft dysfunction: identifying the missing pieces of the puzzle. Eur Respir Rev 2022; 31:31/165/220060. [PMID: 35896274 DOI: 10.1183/16000617.0060-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/19/2022] [Indexed: 11/05/2022] Open
Abstract
Lung transplantation is the optimal treatment for selected patients with end-stage chronic lung diseases. However, chronic lung allograft dysfunction remains the leading obstacle to improved long-term outcomes. Traditionally, lung allograft rejection has been considered primarily as a manifestation of cellular immune responses. However, in reality, an array of complex, interacting and multifactorial mechanisms contribute to its emergence. Alloimmune-dependent mechanisms, including T-cell-mediated rejection and antibody-mediated rejection, as well as non-alloimmune injuries, have been implicated. Moreover, a role has emerged for autoimmune responses to lung self-antigens in the development of chronic graft injury. The aim of this review is to summarise the immune processes involved in the pathogenesis of chronic lung allograft dysfunction, with advanced insights into the role of innate immune pathways and crosstalk between innate and adaptive immunity, and to identify gaps in current knowledge.
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Affiliation(s)
- Saskia Bos
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK.,Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Luke Milross
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Andrew J Filby
- Flow Cytometry Core and Innovation, Methodology and Application Research Theme, Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Robin Vos
- Dept of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium.,University Hospitals Leuven, Dept of Respiratory Diseases, Leuven, Belgium
| | - Andrew J Fisher
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK .,Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
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13
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Huang HJ, Schechtman K, Askar M, Bernadt C, Mittler B, Dore P, Witt C, Byers D, Vazquez-Guillamet R, Halverson L, Nava R, Puri V, Gelman A, Kreisel D, Hachem RR. A pilot randomized controlled trial of de novo belatacept-based immunosuppression following anti-thymocyte globulin induction in lung transplantation. Am J Transplant 2022; 22:1884-1892. [PMID: 35286760 PMCID: PMC9262777 DOI: 10.1111/ajt.17028] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 01/25/2023]
Abstract
The development of donor-specific antibodies (DSA) after lung transplantation is common and results in adverse outcomes. In kidney transplantation, Belatacept has been associated with a lower incidence of DSA, but experience with Belatacept in lung transplantation is limited. We conducted a two-center pilot randomized controlled trial of de novo immunosuppression with Belatacept after lung transplantation to assess the feasibility of conducting a pivotal trial. Twenty-seven participants were randomized to Control (Tacrolimus, Mycophenolate Mofetil, and prednisone, n = 14) or Belatacept-based immunosuppression (Tacrolimus, Belatacept, and prednisone until day 89 followed by Belatacept, Mycophenolate Mofetil, and prednisone, n = 13). All participants were treated with rabbit anti-thymocyte globulin for induction immunosuppression. We permanently stopped randomization and treatment with Belatacept after three participants in the Belatacept arm died compared to none in the Control arm. Subsequently, two additional participants in the Belatacept arm died for a total of five deaths compared to none in the Control arm (log rank p = .016). We did not detect a significant difference in DSA development, acute cellular rejection, or infection between the two groups. We conclude that the investigational regimen used in this study is associated with increased mortality after lung transplantation.
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Affiliation(s)
| | | | - Medhat Askar
- Department of Pathology and Laboratory Medicine, Texas A & M College of Medicine
| | - Cory Bernadt
- Department of Pathology and Immunology, Washington University in St. Louis
| | - Brigitte Mittler
- Division of Pulmonary and Critical Care, Washington University in St. Louis
| | - Peter Dore
- Division of Biostatistics, Washington University in St. Louis
| | - Chad Witt
- Division of Pulmonary and Critical Care, Washington University in St. Louis
| | - Derek Byers
- Division of Pulmonary and Critical Care, Washington University in St. Louis
| | | | - Laura Halverson
- Division of Pulmonary and Critical Care, Washington University in St. Louis
| | - Ruben Nava
- Division of Cardiothoracic Surgery, Washington University in St. Louis
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University in St. Louis
| | - Andrew Gelman
- Division of Cardiothoracic Surgery, Washington University in St. Louis
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University in St. Louis
| | - Ramsey R. Hachem
- Division of Pulmonary and Critical Care, Washington University in St. Louis
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14
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Ma N, Guo JP, Zhao XY, Xu LP, Zhang XH, Wang Y, Mo XD, Zhang YY, Liu YR, Zhao XS, Cheng YF, Liu KY, Huang XJ, Chang YJ. Prevalence and risk factors of antibodies to HLA according to different cut-off values of mean fluorescence intensity in haploidentical allograft candidates: A prospective study of 3805 subjects. HLA 2022; 100:312-324. [PMID: 35681275 DOI: 10.1111/tan.14704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/07/2022] [Accepted: 06/05/2022] [Indexed: 12/30/2022]
Abstract
The importance of anti-HLA antibodies in transplantation settings, such as HLA-mismatched or haploidentical hematopoietic stem cell transplantation and platelet refractoriness, is widely recognized. In previous reports, it was mentioned that several cut-off values of donor-specific anti-HLA antibodies mean fluorescence intensity (MFI) were related to graft rejection in the environment of HLA mismatched stem cell transplantation and the aim of this study was to investigate the prevalence and risk factors of anti-HLA antibodies according to those cut-off values of MFI. A total of 3805 patients with hematologic disease were prospectively enrolled and analyzed. When using MFI of anti-HLA antibodies ≥500, ≥1000, ≥1500, ≥2000, ≥5000, and ≥ 10,000 as cut-off values for positivity, the prevalence of class I or II anti-HLA antibodies ranged from 4.6% to 20.2% in all cases. When the MFI cut-off value was ≥500 for positivity, multivariate analysis indicated that platelet transfusion, underlying disease, and pregnancy were the most important risk factors for the presence of anti-HLA antibodies for the total patients. Subgroup analysis according to age, gender, and underlying disease showed that pregnancy was the most important risk factor for the presence of anti-HLA antibodies. For all patients (n = 3805), when anti-HLA antibody positivity was defined according to different MFI cut-off values, including ≥1000, ≥1500, ≥2000, ≥5000, and ≥ 10,000, an association of platelet transfusion and pregnancy with anti-HLA antibodies was also demonstrated. Our results suggest that pregnancy and platelet transfusion are the main risk factors for the prevalence of anti-HLA antibodies in haploid allograft candidates, providing evidence for guiding the evaluation of anti-HLA antibodies and helping donor selection for HLA-mismatched transplant candidates.
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Affiliation(s)
- Ning Ma
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Jia-Pei Guo
- Department of Immunology, School of Basic Medical Sciences, Peking University. NHC Key Laboratory of Medical Immunology (Peking University), Beijing, China
| | - Xiang-Yu Zhao
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Lan-Ping Xu
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Hui Zhang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yu Wang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Dong Mo
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yuan-Yuan Zhang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yan-Rong Liu
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Su Zhao
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yi-Fei Cheng
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Kai-Yan Liu
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Jun Huang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Ying-Jun Chang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
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15
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Cone BD, Zhang JQ, Sosa RA, Calabrese F, Reed EF, Fishbein GA. Phosphorylated S6 ribosomal protein expression by immunohistochemistry correlates with de novo donor-specific HLA antibodies in lung allograft recipients. J Heart Lung Transplant 2021; 40:1164-1171. [PMID: 34330604 DOI: 10.1016/j.healun.2021.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 06/12/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Per the ISHLT 2016 definition, a C4d-positive lung biopsy is required to meet criteria for definite antibody-mediated rejection (AMR). Unfortunately, C4d has poor sensitivity and specificity, and low inter-rater reliability. Phosphorylated S6 ribosomal protein (p-S6RP) expressed via the mTOR pathway has been shown to be a biomarker of AMR and correlates with donor-specific antibodies (DSA) in heart allografts. However, p-S6RP immunohistochemistry (IHC) in the setting of pulmonary AMR has yet to be evaluated. We sought to determine whether p-S6RP IHC performed on lung biopsies correlates with de novo DSA. METHODS IHC for p-S6RP performed on 26 biopsies from lung transplant recipients with de novo HLA DSA (DSA+) and 28 biopsies from patients with no DSA (DSA-) were evaluated by 3 pathologists who independently scored the degree of alveolar macrophage and pneumocyte staining. Staining in ≥50% of the biopsy as determined by at least 2 pathologists was considered positive. RESULTS Twenty-one (81%) DSA+ biopsies stained positive for p-S6RP in pneumocytes and 21 (81%) in macrophages. Six DSA- biopsies (21%) stained positive for p-S6RP in pneumocytes, 6 (21%) were positive in macrophages. Pneumocyte p-S6RP staining was 81% sensitive and 79% specific for DSA. Macrophage staining showed the same sensitivity and specificity but with lower inter-rater agreement (κ = 0.53 vs 0.68). CONCLUSIONS This study demonstrates a positive relationship between de novo DSA and p-S6RP expression in pneumocytes and macrophages using IHC. p-S6RP is relatively sensitive and specific, and has superior inter-rater reliability compared to C4d.
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Affiliation(s)
- Brian D Cone
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jennifer Q Zhang
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Rebecca A Sosa
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Elaine F Reed
- David Geffen School of Medicine at UCLA, Los Angeles, California
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16
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Abstract
PURPOSE OF REVIEW The development of donor-specific antibodies (DSA) after lung transplantation has been recognized as an important risk factor for poor outcomes over the past 20 years. Recently, this has been a focus of intense research, and the purpose of this review is to summarize our current understanding of humoral responses and important recent findings as well as to identify areas of future research. RECENT FINDINGS Recent studies have identified donor-derived cell-free DNA (ddcfDNA) as an important biomarker associated with antibody-mediated rejection (AMR). Importantly, ddcfDNA levels are noted to be elevated approximately 3 months before the onset of clinical allograft dysfunction, making ddcfDNA a particularly appealing biomarker to predict the onset of AMR. Additional notable recent findings include the identification of an independent association between the isolation of Pseudomonas aeruginosa from respiratory specimens and the development of DSA. This finding provides potential insights into crosstalk between innate and alloimmune responses and identifies a potential therapeutic target to prevent the development of DSA. SUMMARY Progress in the field of humoral responses after lung transplantation has been slow, but ongoing and future research in this area are critically necessary to improve patient outcomes in the future.
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17
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Gochi F, Chen-Yoshikawa TF, Kayawake H, Ohsumi A, Tanaka S, Yamada Y, Yutaka Y, Nakajima D, Hamaji M, Yurugi K, Hishida R, Date H. Comparison of de novo donor-specific antibodies between living and cadaveric lung transplantation. J Heart Lung Transplant 2021; 40:607-13. [PMID: 34078558 DOI: 10.1016/j.healun.2021.03.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 02/24/2021] [Accepted: 03/20/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Despite growing interest in donor-specific antibodies (DSAs) and antibody-mediated rejection (AMR) in lung transplantation (LTx), no study evaluating the outcomes in recipients with de novo DSAs (dnDSAs) in living-donor lobar LTx (LDLLT) exists. We compared various characteristics of DSAs in LDLLT with those in cadaveric LTx (CLT) based on prospectively collected data. METHODS Between October 2009 and September 2019, 211 recipients underwent LTx (128 CLTs and 83 LDLLTs). We reviewed 108 CLTs and 74 LDLLTs to determine the characteristics and clinical impact of dnDSAs. Eighteen data-deficient cases, 7 cases with preformed DSAs, and 4 re-transplants were excluded. RESULTS There were significant differences between CLT and LDLLT patients in age, primary disease, ischemic time, and number of human leukocyte antigen mismatches per donor. The dnDSA incidence in LDLLT (6.8%) was significantly lower than that in CLT (19.4%, p = 0.02). The dnDSAs appeared later in LDLLT (mean 1,256 days) than in CLT (mean 196 days, p = 0.003). According to Cox models analyzed using dnDSA as a time-dependent covariate, dnDSA positivity was significantly associated with a poor overall survival (OS; hazard ratio [HR] 3.46, 95% confidence interval [CI] 1.59-7.57, p = 0.002) and poor CLAD-free survival in case of CLT (HR: 2.23, 95% CI: 1.08-4.63, p = 0.003). However, no such significant associations were noted in case of LDLLT. CONCLUSIONS The dnDSA occurrence was significantly lower and later in LDLLT than in CLT. Furthermore, dnDSA-positivity was significantly associated with worse OS and CLAD-free survival after CLT but not after LDLLT.
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18
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Abstract
PURPOSE OF REVIEW It has been well established that antibody to donor HLA pretransplant and the development of anti-human leukocyte antigen (HLA) antibodies posttransplant contribute to inferior graft survival outcomes. This article serves to review the current status of the management of pretransplant sensitized intestinal transplant candidate as well as to review posttransplant care of patients that harbor antidonor HLA antibodies. RECENT FINDINGS The intestinal transplant candidate oftentimes presents for transplant listing with high levels of anti-HLA antibodies that necessitate a careful preoperative strategy to avoid a donor-recipient pair that would result in a positive crossmatch. In the end, donor intestine offer acceptance is based on a balance between recipient clinical needs and allowable immunologic risk tolerance. The use of virtual crossmatching (VXM) enables the transplant center to effectively gauge the immunologic risk of each potential donor-recipient pair far in advance of allocating resources toward pursuing a donor organ. In those candidates with high levels of preformed donor anti-HLA antibodies, desensitization with a novel technique of donor splenic perfusion has been described as well as a single-center experience with a conventional desensitizing protocol. Posttransplant, with the use of a denovo donor-specific antibody (dnDSA) monitoring and treatment protocol, the well known deleterious effects of dnDSA can potentially be ameliorated, thus improving outcome. Efforts to establish a formal histologic criteria for antibody-mediated rejection (ABMR) in the intestinal graft continues to evolve with recent findings describing the relationship between DSA and histopathologic findings. SUMMARY Techniques such as the use of VXM, novel desensitization methods and protocols, monitoring and eradicating dnDSA, along with establishing new criteria for ABMR have all contributed to improving the outcomes in transplanting the immunologically challenging intestine.
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19
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Benazzo A, Worel N, Schwarz S, Just U, Nechay A, Lambers C, Böhmig G, Fischer G, Koren D, Muraközy G, Knobler R, Klepetko W, Hoetzenecker K, Jaksch P. Outcome of Extracorporeal Photopheresis as an Add-On Therapy for Antibody-Mediated Rejection in Lung Transplant Recipients. Transfus Med Hemother 2020; 47:205-213. [PMID: 32595425 DOI: 10.1159/000508170] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/26/2020] [Indexed: 01/02/2023] Open
Abstract
Introduction The diagnosis and treatment of antibody-mediated rejection (AMR) after lung transplantation has recently gained recognition within the transplant community. Extracorporeal photopheresis (ECP), currently used to treat chronic lung allograft dysfunction, modulates various pathways of the immune system known to be involved in AMR. We hypothesize that adding ECP to established AMR treatments could prevent the rebound of donor-specific antibodies (DSA). Objectives This study aimed to analyze the role of ECP as an add-on therapy to prevent the rebound of DSA. Methods Lung transplant recipients who received ECP as an add-on therapy for pulmonary AMR between January 2010 and January 2019 were included in this single-center retrospective analysis. Baseline demographics of the patients, as well as their immunological characteristics and long-term transplant outcomes, were analyzed. Results A total of 41 patients developed clinical AMR during the study period. Sixteen patients received ECP as an add-on therapy after first-line AMR treatment. Among the 16 patients, 2 (13%) had pretransplant DSA, both against human leukocyte antigen (HLA) class I (B38, B13, and C06). Fifteen patients (94%) developed de novo DSA (dnDSA), i.e., 10 (63%) against class I and 14 (88%) against class II. The median time to dnDSA after lung transplantation was 361 days (range 25-2,548). According to the most recent International Society of Heart and Lung Transplantation (ISHLT) consensus report, 2 (13%) patients had definite clinical AMR, 6 (38%) had probable AMR, and 7 (44%) had possible AMR. The median mean fluorescence intensity (MFI) of dnDSA at the time of clinical diagnosis was 4,220 (range 1,319-10,552) for anti-HLA class I and 10,953 (range 1,969-27,501) for anti-HLA class II antibodies. ECP was performed for a median of 14 cycles (range 1-64). MFI values of dnDSA against HLA classes I and II were significantly reduced over the treatment period (for anti-class I: 752; range 70-2,066; for anti-class II: 5,612; range 1,689-21,858). The 1-year survival rate was 55%. No adverse events related to ECP were reported in any of the patients. Conclusions ECP is associated with a reduction of dnDSA in lung transplant recipients affected by AMR. Prospective studies are warranted to confirm the beneficial effects of ECP in the setting of AMR.
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Affiliation(s)
- Alberto Benazzo
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Nina Worel
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Stefan Schwarz
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Ulrike Just
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Anna Nechay
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Lambers
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Georg Böhmig
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gottfried Fischer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniela Koren
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Gabriela Muraközy
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Robert Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Walter Klepetko
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Konrad Hoetzenecker
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Jaksch
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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20
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Abstract
Rejection is a major complication following lung transplantation. Acute cellular rejection, lymphocytic bronchiolitis, and antibody-mediated rejection (AMR) are all risk factors for the subsequent development of chronic lung allograft dysfunction (CLAD). Acute cellular rejection and lymphocytic bronchiolitis have well defined histopathologic diagnostic criteria and grading. Diagnosis of AMR requires a multidisciplinary approach. CLAD is the major barrier to long-term survival following lung transplantation. The most common phenotype of CLAD is bronchiolitis obliterans syndrome (BOS) which is defined by a persistent obstructive decline in lung function. Restrictive allograft dysfunction (RAS) is a second phenotype of CLAD and is associated with a worse prognosis. This article will review the diagnosis, staging, clinical presentation, and treatment of acute rejection, AMR, and CLAD following lung transplantation.
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Affiliation(s)
- Amit D Parulekar
- Section of Pulmonary, Critical Care, and Sleep, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Christina C Kao
- Section of Pulmonary, Critical Care, and Sleep, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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21
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Dick A, Humpe A, Kauke T. Impact, Screening, and Therapy of HLA Antibodies in Patients before and after Lung Transplantation. Transfus Med Hemother 2019; 46:337-347. [PMID: 31832059 DOI: 10.1159/000502124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/13/2019] [Indexed: 12/29/2022] Open
Abstract
Since almost 30 years, lung transplantation is a considerable therapeutic option in patients suffering from end-stage lung disease. Up to now, the impact of donor-specific antibodies directed against donor HLA (human leukocyte antigen) before and after transplantation is still a matter of debate. As histocompatibility testing is not required for each patient according to the current national guidelines and Eurotransplant recommendations for lung transplantation, each transplantation unit has to establish a local protocol together with the tissue typing laboratory how to implement an immunological risk assessment strategy for their patients while enabling access to transplantation. Desensitization regimens might help in case of highly alloimmunized patients waiting for urgent transplantation.
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Affiliation(s)
- Andrea Dick
- Division of Transfusion Medicine, Cellular Therapeutics, and Hemostaseology, University Clinic LMU Munich, Munich, Germany
| | - Andreas Humpe
- Division of Transfusion Medicine, Cellular Therapeutics, and Hemostaseology, University Clinic LMU Munich, Munich, Germany
| | - Teresa Kauke
- Division of Transfusion Medicine, Cellular Therapeutics, and Hemostaseology, University Clinic LMU Munich, Munich, Germany.,Division of Thoracic Surgery, University Clinic LMU Munich, Munich, Germany
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22
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Ju L, Suberbielle C, Li X, Mooney N, Charron D. HLA and lung transplantation. Front Med 2019; 13:298-313. [DOI: 10.1007/s11684-018-0636-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 01/27/2018] [Indexed: 12/25/2022]
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23
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Hachem RR. The impact of non-HLA antibodies on outcomes after lung transplantation and implications for therapeutic approaches. Hum Immunol 2019; 80:583-587. [PMID: 31005400 DOI: 10.1016/j.humimm.2019.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/09/2019] [Accepted: 04/13/2019] [Indexed: 01/12/2023]
Abstract
The role of donor-specific antibodies (DSA) to mismatched human leukocyte antigens (HLA) in lung allograft rejection has been recognized over the past 20 years. During this time, there has been growing experience and recognition of an important role for non-HLA antibodies in lung allograft rejection. Multiple self-antigens have been identified that elicit autoimmune responses including collagen V, K-α 1 tubulin, angiotensin type 1 receptor, and endothelin type A receptor, but it is likely that other antigens elicit similar responses. The paradigm for the pathogenesis of these autoimmune responses consists of exposure of sequestered self-antigens followed by loss of peripheral tolerance, which then promotes allograft rejection. Studies have focused mainly on the impact of autoimmune responses on the development of Bronchiolitis Obliterans Syndrome or its mouse model surrogate. However, there are emerging data that illustrate that non-HLA antibodies can induce acute antibody-mediated rejection (AMR) after lung transplantation. Treatment has focused on antibody-depletion protocols, but experience is limited to cohort studies and appropriate controlled trials have not been conducted. It is noteworthy that depletion of non-HLA antibodies has been associated with favorable clinical outcomes. Clearly, additional studies are needed to identify the optimal therapeutic approaches to non-HLA antibodies in clinical practice.
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Affiliation(s)
- Ramsey R Hachem
- Washington University School of Medicine, Division of Pulmonary & Critical Care, 4523 Clayton Ave., Campus Box 8052, St. Louis, MO 63110, United States.
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24
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Lv M, Zhai SZ, Wang Y, Xu LP, Zhang XH, Chen H, Chen YH, Wang FR, Han W, Sun YQ, Cheng YF, Yan CH, Mo XD, Liu KY, Chang YJ, Huang XJ, Zhao XY. Class I and II human leukocyte antibodies in pediatric haploidentical allograft candidates: prevalence and risk factors. Bone Marrow Transplant 2019; 54:1287-1294. [DOI: 10.1038/s41409-018-0427-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 11/26/2018] [Accepted: 12/09/2018] [Indexed: 12/13/2022]
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25
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Siddiqui AS, Kumar G, Majumdar T, Graviss EA, Nguyen DT, Goodarzi A, Kaleekal T. Association of methacholine challenge test with diagnosis of chronic lung allograft dysfunction in lung transplant patients. Clin Transplant 2018; 32:e13397. [PMID: 30192029 DOI: 10.1111/ctr.13397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 08/08/2018] [Accepted: 08/23/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) is a complication of lung transplantation. We sought to determine whether bronchial hyperresponsiveness detected by the methacholine challenge test (MCT) at 3 months after lung transplant (LT) predicts the development of CLAD. METHODS We performed a retrospective cohort study of 140 LT patients between 1/2008 and 6/2014 who underwent MCT at 3 months after LT. Pearson's chi-squared test and Kruskal-Wallis test were used to compare categorical and continuous variables, respectively. Cox proportional hazards modeling was used to evaluate the association between CLAD and MCT. RESULTS Methacholine challenge test+ was associated with the development of overall CLAD (adjusted hazards ratio [aHR]: 3.47; 95% confidence interval [95% CI]: 1.71, 7.03; P = 0.001) and CLAD within 3 years (aHR: 4.98; 95%CI: 1.84, 13.48; P = 0.002). Subgroup analysis showed that MCT (+) is associated with overall CLAD in single lung transplant (SLT) (aHR: 8.18; 95% CI: 2.22, 30.09; P = 0.002), double lung transplant (DLT) (aHR: 3.27; 95% CI: 1.22, 8.78; P = 0.02) and CLAD within 3 years in DLT patients (aHR: 6.76; 95% CI: 1.71, 26.74; P = 0.01). CONCLUSION Methacholine challenge test+ at 3 months after LT is associated with the development of overall CLAD. Positive MCT could predict the development of early CLAD within 3 years in DLT patients.
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Affiliation(s)
- Atif S Siddiqui
- Pulmonary and Critical Care, Houston Methodist Hospital, Houston, Texas
| | - Gagan Kumar
- Pulmonary and Critical Care, Northeast Georgia Medical Center, Gainesville, Georgia
| | | | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Ahmad Goodarzi
- Pulmonary Transplant, Houston Methodist Hospital, Houston, Texas
| | - Thomas Kaleekal
- Pulmonary Transplant, Houston Methodist Hospital, Houston, Texas
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26
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Hachem RR, Kamoun M, Budev MM, Askar M, Ahya VN, Lee JC, Levine DJ, Pollack MS, Dhillon GS, Weill D, Schechtman KB, Leard LE, Golden JA, Baxter-Lowe L, Mohanakumar T, Tyan DB, Yusen RD. Human leukocyte antigens antibodies after lung transplantation: Primary results of the HALT study. Am J Transplant 2018; 18:2285-2294. [PMID: 29687961 PMCID: PMC6117197 DOI: 10.1111/ajt.14893] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/20/2018] [Accepted: 04/17/2018] [Indexed: 01/25/2023]
Abstract
Donor-specific antibodies (DSA) to mismatched human leukocyte antigens (HLA) are associated with worse outcomes after lung transplantation. To determine the incidence and characteristics of DSA early after lung transplantation, we conducted a prospective multicenter observational study that used standardized treatment and testing protocols. Among 119 transplant recipients, 43 (36%) developed DSA: 6 (14%) developed DSA only to class I HLA, 23 (53%) developed DSA only to class II HLA, and 14 (33%) developed DSA to both class I and class II HLA. The median DSA mean fluorescence intensity (MFI) was 3197. We identified a significant association between the Lung Allocation Score and the development of DSA (HR = 1.02, 95% CI: 1.001-1.03, P = .047) and a significant association between DSA with an MFI ≥ 3000 and acute cellular rejection (ACR) grade ≥ A2 (HR = 2.11, 95% CI: 1.04-4.27, P = .039). However, we did not detect an association between DSA and survival. We conclude that DSA occur frequently early after lung transplantation, and most target class II HLA. DSA with an MFI ≥ 3000 have a significant association with ACR. Extended follow-up is necessary to determine the impact of DSA on other important outcomes.
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Affiliation(s)
- Ramsey R. Hachem
- Pulmonary and Critical Care, Washington University School of Medicine
| | - Malek Kamoun
- Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine
| | | | | | - Vivek N. Ahya
- Pulmonary and Critical Care, University of Pennsylvania School of Medicine
| | - James C. Lee
- Pulmonary and Critical Care, University of Pennsylvania School of Medicine
| | - Deborah J. Levine
- Pulmonary and Critical Care, University of Texas Health Science Center, San Antonio
| | | | | | - David Weill
- Pulmonary and Critical Care, Stanford University School of Medicine
| | | | - Lorriana E. Leard
- Pulmonary and Critical Care, University of California, San Francisco
| | - Jeffrey A. Golden
- Pulmonary and Critical Care, University of California, San Francisco
| | - LeeAnn Baxter-Lowe
- Pediatrics, Keck School of Medicine of University of Southern California
| | | | | | - Roger D. Yusen
- Pulmonary and Critical Care, Washington University School of Medicine
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27
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Hulbert AL, Pavlisko EN, Palmer SM. Current challenges and opportunities in the management of antibody-mediated rejection in lung transplantation: . Curr Opin Organ Transplant 2018; 23:308-15. [DOI: 10.1097/mot.0000000000000537] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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28
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Abstract
Long-term survival after lung transplantation (LTx) is limited by chronic rejection (CR). Therapeutic strategies for CR have been largely unsuccessful, making prevention of CR an important and challenging therapeutic approach. In the current review, we will discuss current clinical evidence regarding prevention of CR after LTx.
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Affiliation(s)
- Anke Van Herck
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Stijn E Verleden
- Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Geert M Verleden
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
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29
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Abstract
Despite induction immunosuppression and the use of aggressive maintenance immunosuppressive regimens, acute allograft rejection following lung transplantation is still a problem with important diagnostic and therapeutic challenges. As well as causing early graft loss and mortality, acute rejection also initiates the chronic alloimmune responses and airway-centred inflammation that predispose to bronchiolitis obliterans syndrome (BOS), also known as chronic lung allograft dysfunction (CLAD), which is a major source of morbidity and mortality after lung transplantation. Cellular responses to human leukocyte antigens (HLAs) on the allograft have traditionally been considered the main mechanism of acute rejection, but the influence of humoral immunity is increasingly recognised. As with other several other solid organ transplants, antibody-mediated rejection (AMR) is now a well-accepted and distinct clinical entity in lung transplantation. While acute cellular rejection (ACR) has defined histopathological criteria, transbronchial biopsy is less useful in AMR and its diagnosis is complicated by challenges in the measurement of antibodies directed against donor HLA, and a determination of their significance. Increasing awareness of the importance of non-HLA antigens further clouds this issue. Here, we review the pathophysiology, diagnosis, clinical presentation and treatment of ACR and AMR in lung transplantation, and discuss future potential biomarkers of both processes that may forward our understanding of these conditions.
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Affiliation(s)
- Mark Benzimra
- Heart and Lung Transplant Unit, St Vincent's Hospital, Sydney, Australia
| | - Greg L Calligaro
- Division of Pulmonology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Allan R Glanville
- Heart and Lung Transplant Unit, St Vincent's Hospital, Sydney, Australia
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30
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Abstract
PURPOSE OF REVIEW In recent years, there has been increasing awareness and appreciation for the role of humoral immune responses in lung allograft rejection. This review summarizes our current understanding of this role and the associated challenges. RECENT FINDINGS Recent studies have described a syndrome of acute antibody-mediated rejection with a generally poor response to therapy and a high mortality. In addition, there is significant evidence implicating donor-specific human leukocyte antigen antibodies in the development of chronic lung allograft dysfunction. However, the optimal intervention to mitigate the risk of chronic lung allograft dysfunction after donor-specific human leukocyte antigen antibodies development remains unclear. SUMMARY There is mounting evidence that humoral immune responses play an important role in lung allograft rejection. However, therapeutic implications of this increased awareness have been limited. Indeed, there is insufficient evidence to adequately guide therapy, and the optimal treatment is unknown.
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31
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Kameda K, Nakasone H, Komiya Y, Kanda J, Gomyo A, Hayakawa J, Akahoshi Y, Tamaki M, Harada N, Kusuda M, Ugai T, Ishihara Y, Kawamura K, Sakamoto K, Sato M, Tanihara A, Wada H, Terasako-saito K, Kikuchi M, Kimura S, Kako S, Kanda Y. Positive Cytotoxic Crossmatch Predicts Delayed Neutrophil Engraftment in Allogeneic Hematopoietic Cell Transplantation from HLA-Mismatched Related Donors. Biol Blood Marrow Transplant 2017; 23:1895-902. [DOI: 10.1016/j.bbmt.2017.06.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 06/28/2017] [Indexed: 02/08/2023]
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32
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Abbes S, Metjian A, Gray A, Martinu T, Snyder L, Chen DF, Ellis M, Arepally GM, Onwuemene O. Human Leukocyte Antigen Sensitization in Solid Organ Transplantation: A Primer on Terminology, Testing, and Clinical Significance for the Apheresis Practitioner. Ther Apher Dial 2017; 21:441-450. [PMID: 28880430 DOI: 10.1111/1744-9987.12570] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/24/2017] [Accepted: 04/25/2017] [Indexed: 01/02/2023]
Abstract
The human leukocyte antigen (HLA) system is an important immunologic barrier that must be considered for successful solid organ transplantation. Formation of donor-specific HLA antibodies in solid organ transplantation is an important cause of allograft injury and may contribute to recipient morbidity and mortality. Therapeutic plasma exchange is often requested to lower HLA antibody levels prior to or after transplantation and for management of HLA antibodies in the context of organ rejection. In this review, we summarize the current terminology, laboratory testing, and clinical significance of HLA sensitization in the solid organ transplant population. Furthermore, to illustrate applications of HLA testing in clinical practice, we summarize our own lung and kidney institutional protocols for managing HLA antibodies in the peri-transplant setting.
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Affiliation(s)
- Sarah Abbes
- Institut du thorax, Service de pneumologie et unite de transplantation thoracique, Centre Hospitalier Universitaire, Nantes, France.,Department of Medicine, Division of Hematology, Duke University School of Medicine, Durham, NC, USA
| | - Ara Metjian
- Department of Medicine, Division of Hematology, Duke University School of Medicine, Durham, NC, USA
| | - Alice Gray
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Tereza Martinu
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA.,Department of Medicine, Division of Respirology, University of Toronto, Toronto, ON, Canada
| | - Laurie Snyder
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Dong-Feng Chen
- Department of Pathology, Division of Pathology Clinical Services, Duke University School of Medicine, Durham, NC, USA
| | - Matthew Ellis
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, USA
| | - Gowthami M Arepally
- Department of Medicine, Division of Hematology, Duke University School of Medicine, Durham, NC, USA
| | - Oluwatoyosi Onwuemene
- Department of Medicine, Division of Hematology, Duke University School of Medicine, Durham, NC, USA
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33
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Arias M, Serón D, Herrero I, Rush DN, Wiebe C, Nickerson PW, Ussetti P, Rodrigo E, de Cos M. Subclinical Antibody-Mediated Rejection. Transplantation 2017; 101:S1-S18. [DOI: 10.1097/tp.0000000000001735] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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34
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Ensor CR, Yousem SA, Marrari M, Morrell MR, Mangiola M, Pilewski JM, D'Cunha J, Wisniewski SR, Venkataramanan R, Zeevi A, McDyer JF. Proteasome Inhibitor Carfilzomib-Based Therapy for Antibody-Mediated Rejection of the Pulmonary Allograft: Use and Short-Term Findings. Am J Transplant 2017; 17:1380-1388. [PMID: 28173620 DOI: 10.1111/ajt.14222] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 01/08/2017] [Accepted: 01/29/2017] [Indexed: 01/25/2023]
Abstract
We present this observational study of lung transplant recipients (LTR) treated with carfilzomib (CFZ)-based therapy for antibody-mediated rejection (AMR) of the lung. Patients were considered responders to CFZ if complement-1q (C1q)-fixing ability of their immunodominant (ID) donor-specific anti-human leukocyte antibody (DSA) was suppressed after treatment. Treatment consisted of CFZ plus plasma exchange and immunoglobulins. Fourteen LTRs underwent CFZ for 20 ID DSA AMR. Ten (71.4%) of LTRs responded to CFZ. DSA IgG mean fluorescence intensity (MFI) fell from 7664 (IQR 3230-11 874) to 1878 (653-7791) after therapy (p = 0.001) and to 1400 (850-8287) 2 weeks later (p = 0.001). DSA C1q MFI fell from 3596 (IQR 714-14 405) to <30 after therapy (p = 0.01) and <30 2 weeks later (p = 0.02). Forced expiratory volume in 1s ( FEV1 ) fell from mean 2.11 L pre-AMR to 1.92 L at AMR (p = 0.04). FEV1 was unchanged after CFZ (1.91 L) and subsequently rose to a maximum of 2.13 L (p = 0.01). Mean forced expiratory flow during mid forced vital capacity (25-75) (FEF25-75 ) fell from mean 2.5 L pre-AMR to 1.95 L at AMR (p = 0.01). FEF25-75 rose after CFZ to 2.54 L and reached a maximum of 2.91 L (p = 0.01). Responders had less chronic lung allograft dysfunction or progression versus nonresponders (25% vs. 83%, p = 0.04). No deaths occurred within 120 days and 7 patients died post CFZ therapy of allograft failure. Larger prospective interventional studies are needed to further describe the benefit of CFZ-based therapy for pulmonary AMR.
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Affiliation(s)
- C R Ensor
- School of Pharmacy, Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA.,School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - S A Yousem
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - M Marrari
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - M R Morrell
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - M Mangiola
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - J M Pilewski
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - J D'Cunha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - S R Wisniewski
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - R Venkataramanan
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA.,Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA
| | - A Zeevi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - J F McDyer
- School of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
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35
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Courtwright AM, El-Chemaly S, Dellaripa PF, Goldberg HJ. Survival and outcomes after lung transplantation for non-scleroderma connective tissue-related interstitial lung disease. J Heart Lung Transplant 2016; 36:763-769. [PMID: 28131664 DOI: 10.1016/j.healun.2016.12.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 11/28/2016] [Accepted: 12/26/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients with non-scleroderma connective tissue-related lung disease (NS-CTLD), including rheumatoid arthritis, idiopathic inflammatory myopathies, Sjögren syndrome, mixed connective tissue disease, and systemic lupus erythematosus, may be at risk for worse outcomes after lung transplantation because of immune dysregulation or extrapulmonary manifestations of their underlying disease. We compared survival, acute and chronic rejection, and extrapulmonary organ dysfunction after transplantation in patients with NS-CTLD and idiopathic pulmonary fibrosis (IPF). METHODS This was a retrospective cohort study of patients with NS-CTLD and IPF who were listed in the Scientific Registry of Transplant Recipients and underwent lung transplantation from May 5, 2005, to March 1, 2016. RESULTS Patients with NS-CTLD (n = 275) were younger, a higher percentage female and non-white than patients with IPF (n = 6,346). NS-CTLD patients did not have worse adjusted survival (hazard ratio, 1.14, 95% confidence interval [CI], 0.92-1.42; p = 0.24). They were not more likely to have an episode of acute cellular rejection (odds ratio, 0.96; 95% CI, 0.72-1.28; p = 0.77) or to develop bronchiolitis obliterans syndrome (odds ratio, 0.82; 95% CI, 0.60-1.12; p = 0.21). Patients with NS-CTLD were not more likely to require plasmapheresis or dialysis or to develop a lymphoproliferative malignancy or liver disease after transplantation. CONCLUSIONS We found no significant differences in survival, acute or chronic rejection, or extrapulmonary organ dysfunction in patients who underwent lung transplantation for NS-CTLD compared with IPF. In appropriately selected candidates, NS-CTLD should not be considered a contraindication to lung transplantation.
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Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts; Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Souheil El-Chemaly
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts; Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul F Dellaripa
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, Massachusetts; Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts.
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36
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Nayak DK, Saravanan PB, Bansal S, Naziruddin B, Mohanakumar T. Autologous and Allogenous Antibodies in Lung and Islet Cell Transplantation. Front Immunol 2016; 7:650. [PMID: 28066448 PMCID: PMC5179571 DOI: 10.3389/fimmu.2016.00650] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 12/14/2016] [Indexed: 01/02/2023] Open
Abstract
The field of organ transplantation has undoubtedly made great strides in recent years. Despite the advances in donor-recipient histocompatibility testing, improvement in transplantation procedures, and development of aggressive immunosuppressive regimens, graft-directed immune responses still pose a major problem to the long-term success of organ transplantation. Elicitation of immune responses detected as antibodies to mismatched donor antigens (alloantibodies) and tissue-restricted self-antigens (autoantibodies) are two major risk factors for the development of graft rejection that ultimately lead to graft failure. In this review, we describe current understanding on genesis and pathogenesis of antibodies in two important clinical scenarios: lung transplantation and transplantation of islet of Langerhans. It is evident that when compared to any other clinical solid organ or cellular transplant, lung and islet transplants are more susceptible to rejection by combination of allo- and autoimmune responses.
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Affiliation(s)
- Deepak Kumar Nayak
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center , Phoenix, AZ , USA
| | | | - Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center , Phoenix, AZ , USA
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37
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Walton DC, Hiho SJ, Cantwell LS, Diviney MB, Wright ST, Snell GI, Paraskeva MA, Westall GP. HLA Matching at the Eplet Level Protects Against Chronic Lung Allograft Dysfunction. Am J Transplant 2016; 16:2695-703. [PMID: 27002311 DOI: 10.1111/ajt.13798] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/13/2016] [Accepted: 03/13/2016] [Indexed: 01/25/2023]
Abstract
Donor selection in lung transplantation (LTx) is historically based upon clinical urgency, ABO compatibility, and donor size. HLA matching is not routinely considered; however, the presence or later development of anti-HLA antibodies is associated with poorer outcomes, particularly chronic lung allograft dysfunction (CLAD). Using eplet mismatches, we aimed to determine whether donor/recipient HLA incompatibility was a significant predictor of CLAD. One hundred seventy-five LTx undertaken at the Alfred Hospital between 2008 and 2012 met criteria. Post-LTx monitoring was continued for at least 12 months, or until patient death. HLA typing was performed by sequence-based typing and Luminex sequence-specific oligonucleotide. Using HLAMatchmaker, eplet mismatches between each donor/recipient pairing were analyzed and correlated against incidences of CLAD. HLA-DRB1/3/4/5+DQA/B eplet mismatch was a significant predictor of CLAD (hazard ratio [HR] 3.77, 95% confidence interval [CI]: 1.71-8.29 p < 0.001). When bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS) were analyzed independently, HLA-DRB1/3/4/5 + DQA/B eplet mismatch was shown to significantly predict RAS (HR 8.3, 95% CI: 2.46-27.97 p < 0.001) but not BOS (HR 1.92, 95% CI: 0.64-5.72, p = 0.237). HLA-A/B eplet mismatch was shown not to be a significant predictor when analyzed independently but did provide additional stratification of results. This study illustrates the importance of epitope immunogenicity in defining donor-recipient immune compatibility in LTx.
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Affiliation(s)
- D C Walton
- Victorian Transplantation and Immunogenetics Service, Australian Red Cross Blood Service, Melbourne, Australia
| | - S J Hiho
- Victorian Transplantation and Immunogenetics Service, Australian Red Cross Blood Service, Melbourne, Australia
| | - L S Cantwell
- Victorian Transplantation and Immunogenetics Service, Australian Red Cross Blood Service, Melbourne, Australia
| | - M B Diviney
- Victorian Transplantation and Immunogenetics Service, Australian Red Cross Blood Service, Melbourne, Australia
| | - S T Wright
- Research and Development, Australian Red Cross Blood Service, Sydney, Australia.,Mathematical and Physical Sciences, University of Technology Sydney, Sydney, Australia
| | - G I Snell
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
| | - M A Paraskeva
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
| | - G P Westall
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
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38
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Tikkanen JM, Singer LG, Kim SJ, Li Y, Binnie M, Chaparro C, Chow CW, Martinu T, Azad S, Keshavjee S, Tinckam K. De NovoDQ Donor-Specific Antibodies Are Associated with Chronic Lung Allograft Dysfunction after Lung Transplantation. Am J Respir Crit Care Med 2016; 194:596-606. [DOI: 10.1164/rccm.201509-1857oc] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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39
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Nayak DK, Zhou F, Xu M, Huang J, Tsuji M, Hachem R, Mohanakumar T. Long-Term Persistence of Donor Alveolar Macrophages in Human Lung Transplant Recipients That Influences Donor-Specific Immune Responses. Am J Transplant 2016; 16:2300-11. [PMID: 27062199 PMCID: PMC5289407 DOI: 10.1111/ajt.13819] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 03/10/2016] [Accepted: 04/03/2016] [Indexed: 01/25/2023]
Abstract
Steady-state alveolar macrophages (AMs) are long-lived lung-resident macrophages with sentinel function. Evidence suggests that AM precursors originate during embryogenesis and populate lungs without replenishment by circulating leukocytes. However, their presence and persistence are unclear following human lung transplantation (LTx). Our goal was to examine donor AM longevity and evaluate whether AMs of recipient origin seed the transplanted lungs. Origin of AMs was accessed using donor-recipient HLA mismatches. We demonstrate that 94-100% of AMs present in bronchoalveolar lavage (BAL) were donor derived and, importantly, AMs of recipient origin were not detected. Further, analysis of BAL cells up to 3.5 years post-LTx revealed that the majority of AMs (>87%) was donor derived. Elicitation of de novo donor-specific antibody (DSA) is a major post-LTx complication and a risk factor for development of chronic rejection. The donor AMs responded to anti-HLA framework antibody (Ab) with secretion of inflammatory cytokines. Further, in an experimental murine model, we demonstrate that adoptive transfer of allogeneic AMs stimulated humoral and cellular immune responses to alloantigen and lung-associated self-antigens and led to bronchiolar obstruction. Therefore, donor-derived AMs play an essential role in the DSA-induced inflammatory cascade leading to obliterative airway disease of the transplanted lungs.
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Affiliation(s)
- D K Nayak
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - F Zhou
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - M Xu
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - J Huang
- HIV and Malaria Vaccine Program, Aaron Diamond AIDS Research Center, Affiliate of Rockefeller University, New York, NY
| | - M Tsuji
- HIV and Malaria Vaccine Program, Aaron Diamond AIDS Research Center, Affiliate of Rockefeller University, New York, NY
| | - R Hachem
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - T Mohanakumar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO
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40
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Abstract
Despite improvement in median life expectancy and overall health, some children with cystic fibrosis (CF) progress to end-stage lung or liver disease and become candidates for transplant. Transplants for children with CF hold the promise to extend and improve the quality of life, but barriers to successful long-term outcomes include shortage of suitable donor organs; potential complications from the surgical procedure and immunosuppressants; risk of rejection and infection; and the need for lifelong, strict adherence to a complex medical regimen. This article reviews the indications and complications of lung and liver transplantation in children with CF.
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Affiliation(s)
- Albert Faro
- Department of Pediatrics, Washington University in St. Louis, Campus Box 8116, 660 South Euclid Avenue, St Louis, MO 63110, USA.
| | - Alexander Weymann
- Department of Pediatrics, Washington University in St. Louis, Campus Box 8116, 660 South Euclid Avenue, St Louis, MO 63110, USA
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41
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Liu X, Yue Z, Yu J, Daguindau E, Kushekhar K, Zhang Q, Ogata Y, Gafken PR, Inamoto Y, Gracon A, Wilkes DS, Hansen JA, Lee SJ, Chen JY, Paczesny S. Proteomic Characterization Reveals That MMP-3 Correlates With Bronchiolitis Obliterans Syndrome Following Allogeneic Hematopoietic Cell and Lung Transplantation. Am J Transplant 2016; 16:2342-51. [PMID: 26887344 PMCID: PMC4956556 DOI: 10.1111/ajt.13750] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 02/03/2016] [Accepted: 02/05/2016] [Indexed: 01/25/2023]
Abstract
Improved diagnostic methods are needed for bronchiolitis obliterans syndrome (BOS), a serious complication after allogeneic hematopoietic cell transplantation (HCT) and lung transplantation. For protein candidate discovery, we compared plasma pools from HCT transplantation recipients with BOS at onset (n = 12), pulmonary infection (n = 16), chronic graft-versus-host disease without pulmonary involvement (n = 15) and no chronic complications after HCT (n = 15). Pools were labeled with different tags (isobaric tags for relative and absolute quantification), and two software tools identified differentially expressed proteins (≥1.5-fold change). Candidate proteins were further selected using a six-step computational biology approach. The diagnostic value of the lead candidate, matrix metalloproteinase 3 (MMP3), was evaluated by enzyme-linked immunosorbent assay in plasma of a verification cohort (n = 112) with and without BOS following HCT (n = 76) or lung transplantation (n = 36). MMP3 plasma concentrations differed significantly between patients with and without BOS (area under the receiver operating characteristic curve 0.77). Consequently, MMP3 represents a potential noninvasive blood test for diagnosis of BOS.
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Affiliation(s)
- Xiaowen Liu
- Departement of BioHealth Informatics, Indiana University
School of Informatics and Computing, Indianapolis, IN
| | - Zongliang Yue
- Departement of BioHealth Informatics, Indiana University
School of Informatics and Computing, Indianapolis, IN
| | - Jeffrey Yu
- Department of Pediatrics, Indiana University School of
Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, Indiana
University School of Medicine, Indianapolis, IN, USA
- Department of Microbiology & Immunology, Indiana
University School of Medicine, Indianapolis, IN, USA
- Indiana University Simon Cancer Center, Indiana University
School of Medicine, Indianapolis, IN, USA
| | - Etienne Daguindau
- Department of Pediatrics, Indiana University School of
Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, Indiana
University School of Medicine, Indianapolis, IN, USA
- Department of Microbiology & Immunology, Indiana
University School of Medicine, Indianapolis, IN, USA
- Indiana University Simon Cancer Center, Indiana University
School of Medicine, Indianapolis, IN, USA
| | - Kushi Kushekhar
- Department of Pediatrics, Indiana University School of
Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, Indiana
University School of Medicine, Indianapolis, IN, USA
- Department of Microbiology & Immunology, Indiana
University School of Medicine, Indianapolis, IN, USA
- Indiana University Simon Cancer Center, Indiana University
School of Medicine, Indianapolis, IN, USA
| | - Qing Zhang
- Proteomics Shared Resource, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA
| | - Yuko Ogata
- Proteomics Shared Resource, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA
| | - Philip R. Gafken
- Proteomics Shared Resource, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA
| | - Yoshihiro Inamoto
- Clinical Research Division, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA
- Division of Hematopoietic Stem Cell Transplantation,
National Cancer Center Hospital, Tokyo, Japan
| | - Adam Gracon
- Pulmonary Division, Indiana University School of Medicine,
Indianapolis, IN, USA
| | - David S. Wilkes
- Pulmonary Division, Indiana University School of Medicine,
Indianapolis, IN, USA
| | - John A. Hansen
- Clinical Research Division, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA,
USA
| | - Stephanie J. Lee
- Clinical Research Division, Fred Hutchinson Cancer Research
Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA,
USA
| | - Jake Y. Chen
- Departement of BioHealth Informatics, Indiana University
School of Informatics and Computing, Indianapolis, IN
| | - Sophie Paczesny
- Department of Pediatrics, Indiana University School of
Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, Indiana
University School of Medicine, Indianapolis, IN, USA
- Department of Microbiology & Immunology, Indiana
University School of Medicine, Indianapolis, IN, USA
- Indiana University Simon Cancer Center, Indiana University
School of Medicine, Indianapolis, IN, USA
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42
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Furuya Y, Jayarajan SN, Taghavi S, Cordova FC, Patel N, Shiose A, Leotta E, Criner GJ, Guy TS, Wheatley GH, Kaiser LR, Toyoda Y. The Impact of Alemtuzumab and Basiliximab Induction on Patient Survival and Time to Bronchiolitis Obliterans Syndrome in Double Lung Transplantation Recipients. Am J Transplant 2016; 16:2334-41. [PMID: 26833657 DOI: 10.1111/ajt.13739] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 01/04/2016] [Accepted: 01/10/2016] [Indexed: 01/25/2023]
Abstract
We examined the effect of alemtuzumab and basiliximab induction therapy on patient survival and freedom from bronchiolitis obliterans syndrome (BOS) in double lung transplantation. The United Network for Organ Sharing database was reviewed for adult double lung transplant recipients from 2006 to 2013. The primary outcome was risk-adjusted all-cause mortality. Secondary outcomes included time to BOS. There were 6117 patients were identified, of whom 738 received alemtuzumab, 2804 received basiliximab, and 2575 received no induction. Alemtuzumab recipients had higher lung allocation scores compared with basiliximab and no-induction recipients (41.4 versus 37.9 versus 40.7, p < 0.001) and were more likely to require mechanical ventilation before to transplantation (21.7% versus 6.5% versus 6.2%, p < 0.001). Median survival was longer for alemtuzumab and basiliximab recipients compared with patients who received no induction (2321 versus 2352 versus 1967 days, p = 0.001). Alemtuzumab (hazard ratio 0.80, 95% confidence interval 0.67-0.95, p = 0.009) and basiliximab induction (0.88, 0.80-0.98, p = 0.015) were independently associated with survival on multivariate analysis. At 5 years, alemtuzumab recipients had a lower incidence of BOS (22.7% versus 55.4 versus 55.9%), and its use was independently associated with lower risk of developing BOS on multivariate analysis. While both induction therapies were associated with improved survival, patients who received alemtuzumab had greater median freedom from BOS.
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Affiliation(s)
- Y Furuya
- Division of Pulmonary & Critical Care, Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - S N Jayarajan
- Department of Surgery, Section of Vascular Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - S Taghavi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - F C Cordova
- Section of Pulmonary and Critical Care Medicine, Temple University School of Medicine, Philadelphia, PA
| | - N Patel
- Section of Pulmonary and Critical Care Medicine, Temple University School of Medicine, Philadelphia, PA
| | - A Shiose
- Section of Cardiothoracic Surgery, Temple University School of Medicine, Philadelphia, PA
| | - E Leotta
- Section of Cardiothoracic Surgery, Temple University School of Medicine, Philadelphia, PA
| | - G J Criner
- Section of Pulmonary and Critical Care Medicine, Temple University School of Medicine, Philadelphia, PA
| | - T S Guy
- Section of Cardiothoracic Surgery, Temple University School of Medicine, Philadelphia, PA
| | - G H Wheatley
- Section of Cardiothoracic Surgery, Temple University School of Medicine, Philadelphia, PA
| | - L R Kaiser
- Section of Cardiothoracic Surgery, Temple University School of Medicine, Philadelphia, PA
| | - Y Toyoda
- Section of Cardiothoracic Surgery, Temple University School of Medicine, Philadelphia, PA
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43
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Le Pavec J, Suberbielle C, Lamrani L, Feuillet S, Savale L, Dorfmüller P, Stephan F, Mussot S, Mercier O, Fadel E. De-novo donor-specific anti-HLA antibodies 30 days after lung transplantation are associated with a worse outcome. J Heart Lung Transplant 2016; 35:1067-77. [PMID: 27373824 DOI: 10.1016/j.healun.2016.05.020] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/18/2016] [Accepted: 05/26/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The impact of de-novo donor-specific anti-HLA antibodies (DSA) on patient and graft survival after lung transplantation remains controversial. We analyzed DSA that developed at Day 7 and Month (M) 1, M3, M6 and M12 after lung transplantation and evaluated their impact on chronic lung allograft dysfunction (CLAD) development and survival. METHODS One hundred thirty-four patients who underwent lung transplantation at our institution between November 2007 and August 2013 were included in this study. During the first post-transplant year, 82 (61%) patients developed de novo DSA and 52 (39%) patients did not. Three mean fluorescence intensity (MFI) intervals were used to define scores of anti-HLA antibody positivity: score 4 if MFI was 500 to 1,000; score 6 if MFI was 1,000 to 3,000; and score 8 if MFI was ≥3,000. Patients' records were retrospectively reviewed. RESULTS DSA with MFI scores of ≥4 (hazard ratio [HR] 2.21, 95% confidence interval [CI] 1.08 to 4.54, p = 0.03), 6 (HR 2.63, 95% CI 1.27 to 5.20, p < 0.01) and 8 (HR 2.83, 95% CI 1.42 to 5.67, p < 0.01) at M1; female gender (HR 0.49, 95% CI 0.28 to 0.87, P = 0.01); and with post-operative extracorporeal membrane oxygenation (HR 0.09, 95% CI 0.01 to 0.28, p = 0.02) were significantly associated with CLAD. Multivariate analysis identified score 8 at M1 (HR 2.71, 95% CI 1.34 to 5.47, p < 0.01) as an independent risk factor for mortality. Overall, 1-, 3- and 5-year survival rates were 76%, 52% and 41% compared with 84%, 74% and 70% for patients with or without de-novo DSA at M1, respectively (p = 0.02). CONCLUSION Early de-novo DSA may significantly impact long-term outcomes after lung transplantation and should therefore prompt regular screening.
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Affiliation(s)
- Jérôme Le Pavec
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France.
| | | | - Lilia Lamrani
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Séverine Feuillet
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Laurent Savale
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France; AP-HP, Service de Pneumologie, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Peter Dorfmüller
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Service d'Anatomie Pathologique, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - François Stephan
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France; Service de Réanimation, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Sacha Mussot
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olaf Mercier
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Elie Fadel
- Université Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France; Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France; UMR-S 999, Universitaire Paris-Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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44
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Roux A, Bendib Le Lan I, Holifanjaniaina S, Thomas KA, Hamid AM, Picard C, Grenet D, De Miranda S, Douvry B, Beaumont-Azuar L, Sage E, Devaquet J, Cuquemelle E, Le Guen M, Spreafico R, Suberbielle-Boissel C, Stern M, Parquin F. Antibody-Mediated Rejection in Lung Transplantation: Clinical Outcomes and Donor-Specific Antibody Characteristics. Am J Transplant 2016; 16:1216-28. [PMID: 26845386 DOI: 10.1111/ajt.13589] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 10/13/2015] [Accepted: 10/17/2015] [Indexed: 01/25/2023]
Abstract
In the context of lung transplant (LT), because of diagnostic difficulties, antibody-mediated rejection (AMR) remains a matter of debate. We retrospectively analyzed an LT cohort at Foch Hospital to demonstrate the impact of AMR on LT prognosis. AMR diagnosis requires association of clinical symptoms, donor-specific antibodies (DSAs), and C4d(+) staining and/or histological patterns consistent with AMR. Prospective categorization split patients into four groups: (i) DSA positive, AMR positive (DSA(pos) AMR(pos) ); (ii) DSA positive, AMR negative (DSA(pos) AMR(neg) ); (iii) DSA limited, AMR negative (DSA(Lim) ; equal to one specificity, with mean fluorescence intensity of 500-1000 once); and (iv) DSA negative, AMR negative (DSA(neg) ). AMR treatment consisted of a combination of plasmapheresis, intravenous immunoglobulin and rituximab. Among 206 transplanted patients, 10.7% were DSA(pos) AMR(pos) (n = 22), 40.3% were DSA(pos) AMR(neg) (n = 84), 6% were DSA(Lim) (n = 13) and 43% were DSA(neg) (n = 88). Analysis of acute cellular rejection at month 12 showed higher cumulative numbers (mean plus or minus standard deviation) in the DSA(pos) AMR(pos) group (2.1 ± 1.7) compared with DSA(pos) AMR(neg) (1 ± 1.2), DSA(Lim) (0.75 ± 1), and DSA(neg) (0.7 ± 1.23) groups. Multivariate analysis demonstrated AMR as a risk factor for chronic lung allograft dysfunction (hazard ratio [HR] 8.7) and graft loss (HR 7.56) for DSA(pos) AMR(pos) patients. Our results show a negative impact of AMR on LT clinical course and advocate for an early active diagnostic approach and evaluation of therapeutic strategies to improve prognosis.
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Affiliation(s)
- A Roux
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France.,Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA.,Université Versailles Saint-Quentin-en-Yvelines, UPRES EA220, Suresnes, France
| | - I Bendib Le Lan
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | | | - K A Thomas
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA
| | - A M Hamid
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - C Picard
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - D Grenet
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - S De Miranda
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - B Douvry
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - L Beaumont-Azuar
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - E Sage
- Université Versailles Saint-Quentin-en-Yvelines, UPRES EA220, Suresnes, France.,Thoracic Surgery Department, Foch Hospital, Suresnes, France
| | - J Devaquet
- Intensive Care Unit, Foch Hospital, Suresnes, France
| | - E Cuquemelle
- Thoracic Intensive Care Unit, Foch Hospital, Suresnes, France
| | - M Le Guen
- Anesthesiology Department, Foch Hospital, Suresnes, France
| | - R Spreafico
- Department of Microbiology,Immunology and Molecular Genetics, University of California Los Angeles, Los Angeles, CA.,Institute for Quantitative and Computational Biosciences, University of California Los Angeles, Los Angeles, CA
| | - C Suberbielle-Boissel
- Laboratoire Régional d'Histocompatibilité, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M Stern
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - F Parquin
- Thoracic Intensive Care Unit, Foch Hospital, Suresnes, France
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45
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Levine DJ, Glanville AR, Aboyoun C, Belperio J, Benden C, Berry GJ, Hachem R, Hayes D, Neil D, Reinsmoen NL, Snyder LD, Sweet S, Tyan D, Verleden G, Westall G, Yusen RD, Zamora M, Zeevi A. Antibody-mediated rejection of the lung: A consensus report of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2016; 35:397-406. [PMID: 27044531 DOI: 10.1016/j.healun.2016.01.1223] [Citation(s) in RCA: 256] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 01/28/2016] [Indexed: 12/22/2022] Open
Abstract
Antibody-mediated rejection (AMR) is a recognized cause of allograft dysfunction in lung transplant recipients. Unlike AMR in other solid-organ transplant recipients, there are no standardized diagnostic criteria or an agreed-upon definition. Hence, a working group was created by the International Society for Heart and Lung Transplantation with the aim of determining criteria for pulmonary AMR and establishing a definition. Diagnostic criteria and a working consensus definition were established. Key diagnostic criteria include the presence of antibodies directed toward donor human leukocyte antigens and characteristic lung histology with or without evidence of complement 4d within the graft. Exclusion of other causes of allograft dysfunction increases confidence in the diagnosis but is not essential. Pulmonary AMR may be clinical (allograft dysfunction which can be asymptomatic) or sub-clinical (normal allograft function). This consensus definition will have clinical, therapeutic and research implications.
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Affiliation(s)
- Deborah J Levine
- Pulmonary Disease and Critical Care Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Allan R Glanville
- The Lung Transplant Unit, St. Vincent's Hospital, Sydney, New South Wales, Australia.
| | - Christina Aboyoun
- The Lung Transplant Unit, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - John Belperio
- Pulmonary Disease and Critical Care Medicine, University of California, Los Angeles, California, USA
| | - Christian Benden
- Division of Pulmonary Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Gerald J Berry
- Division of Pathology, Stanford University Medical Center, Palo Alto, California, USA
| | - Ramsey Hachem
- Division of Pulmonology, Washington University, St. Louis, Missouri, USA
| | - Don Hayes
- Department of Pulmonology, The Ohio State University, Columbus, Ohio, USA
| | - Desley Neil
- Department of Pathology, Queen Elizabeth Hospital, Birmingham, UK
| | - Nancy L Reinsmoen
- Department of Immunology, Cedars-Sinai Hospital, Los Angeles, California, USA
| | - Laurie D Snyder
- Department of Pulmonology, Duke University, Durham, North Carolina, USA
| | - Stuart Sweet
- Division of Pulmonology, Washington University, St. Louis, Missouri, USA
| | - Dolly Tyan
- Division of Pathology, Stanford University Medical Center, Palo Alto, California, USA
| | - Geert Verleden
- Department of Pulmonology, University Hospitals Leuven, Leuven, Belgium
| | - Glen Westall
- Department of Pulmonology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Roger D Yusen
- Division of Pulmonology, Washington University, St. Louis, Missouri, USA
| | - Martin Zamora
- Department of Pulmonology, University of Colorado, Denver, Colorado, USA
| | - Adriana Zeevi
- Department of Immunology, University of Pittsburgh, Pittsburgh, Pennyslvania, USA
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Abstract
INTRODUCTION Innate or acquired immune deficiency may show respiratory manifestations, often characterized by small airway involvement. The purpose of this article is to provide an overview of small airway disease across the major causes of immune deficiency. BACKGROUND In patients with common variable immune deficiency, recurrent lower airway infections may lead to bronchiolitis and bronchiectasis. Follicular and/or granulomatous bronchiolitis of unknown origin may also occur. Bronchiolitis obliterans is the leading cause of death after the first year in patients with lung transplantation. Bronchiolitis obliterans also occurs in patients with allogeneic haematopoietic stem cell transplantation, especially in the context of systemic graft-versus-host disease. VIEWPOINT AND CONCLUSION Small airway diseases have different clinical expression and pathophysiology across various causes of immune deficiency. A better understanding of small airways disease pathogenesis in these settings may lead to the development of novel targeted therapies.
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Affiliation(s)
- P-R Burgel
- Université Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
| | - A Bergeron
- Université Paris Diderot, Sorbonne Paris Cité, 75013 Paris, France; Service de pneumologie, hôpital Saint-Louis, AP-HP, 75010 Paris, France
| | - C Knoop
- Department of Chest Medicine, Erasme University Hospital, université libre de Bruxelles, Bruxelles, Belgique
| | - D Dusser
- Université Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
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Abstract
PURPOSE OF REVIEW Pulmonary antibody-mediated rejection (AMR) while contributing to acute and chronic allograft dysfunction remains a diagnostic and therapeutic challenge. The diagnostic tenets upon which AMR is defined will be reviewed in the light of recent studies. RECENT FINDINGS The introduction of solid phase assays such as the Luminex platform has provided a wealth of quantitative data on the presence of anti-human leukocyte antigen (HLA) donor-specific antibodies (DSA). Further studies are required to better define the relationship of circulating DSA and activation of proinflammatory immune pathways that result in allograft dysfunction. The limitations of C4d staining in defining AMR are highlighted from recent studies in lung transplantation and from the 2013 Banff meeting on renal transplantation. SUMMARY The current challenge to the lung transplant community is to agree on a working definition of pulmonary AMR. Only then can we better appreciate the epidemiology, clinical phenotypes, and treatment of AMR.
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Williams KM, Cheng GS, Pusic I, Jagasia M, Burns L, Ho VT, Pidala J, Palmer J, Johnston L, Mayer S, Chien JW, Jacobsohn DA, Pavletic SZ, Martin PJ, Storer BE, Inamoto Y, Chai X, Flowers MED, Lee SJ. Fluticasone, Azithromycin, and Montelukast Treatment for New-Onset Bronchiolitis Obliterans Syndrome after Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:710-6. [PMID: 26475726 DOI: 10.1016/j.bbmt.2015.10.009] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 10/07/2015] [Indexed: 12/13/2022]
Abstract
Bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic cell transplantation (HCT) is associated with high mortality. We hypothesized that inhaled fluticasone, azithromycin, and montelukast (FAM) with a brief steroid pulse could avert progression of new-onset BOS. We tested this in a phase II, single-arm, open-label, multicenter study (NCT01307462). Thirty-six patients were enrolled within 6 months of BOS diagnosis. The primary endpoint was treatment failure, defined as 10% or greater forced expiratory volume in 1 second decline at 3 months. At 3 months, 6% (2 of 36, 95% confidence interval, 1% to 19%) had treatment failure (versus 40% in historical controls, P < .001). FAM was well tolerated. Steroid dose was reduced by 50% or more at 3 months in 48% of patients who could be evaluated (n = 27). Patient-reported outcomes at 3 months were statistically significantly improved for Short-Form 36 social functioning score and mental component score, Functional Assessment of Cancer Therapies emotional well-being, and Lee symptom scores in lung, skin, mouth, and the overall summary score compared to enrollment (n = 24). At 6 months, 36% had treatment failure (95% confidence interval, 21% to 54%, n = 13 of 36, with 6 documented failures, 7 missing pulmonary function tests). Overall survival was 97% (95% confidence interval, 84% to 100%) at 6 months. These data suggest that FAM was well tolerated and that treatment with FAM and steroid pulse may halt pulmonary decline in new-onset BOS in the majority of patients and permit reductions in systemic steroid exposure, which collectively may improve quality of life. However, additional treatments are needed for progressive BOS despite FAM.
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Hayes D, Auletta JJ, Whitson BA, Black SM, Kirkby S, Tobias JD, Mansour HM. Human leukocyte antigen mismatching and survival after lung transplantation in adult and pediatric patients with cystic fibrosis. J Thorac Cardiovasc Surg 2015; 151:549-57.e1. [PMID: 26414151 DOI: 10.1016/j.jtcvs.2015.08.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 08/03/2015] [Accepted: 08/10/2015] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The influence of human leukocyte antigen (HLA) mismatching on survival in adult and pediatric patients with cystic fibrosis (CF) after lung transplantation (LTx) is unknown. METHODS The United Network for Organ Sharing database was queried from 1987 to 2013 to determine the influence of HLA mismatching on survival in adult and pediatric CF LTx recipients by assessing the association of HLA mismatching with survival in first-time adult (aged ≥ 18 years) and pediatric (aged <18 years) recipients. RESULTS Of 3149 adult and 489 pediatric patients with CF, 3145 and 489 were used for univariate Cox analysis, 2687 and 363 for Kaplan-Meier survival analysis, and 2073 and 257 for multivariate Cox analysis, respectively. Univariate analyses in adult and pediatric patients with CF demonstrated conflicting associations between HLA mismatching and survival (adult hazard ratio [HR], 1.0; 95% confidence interval [CI], 0.97-1.1; P = .45 vs pediatric HR, 0.87; 95% CI, 0.77-0.99; P = .032). Multivariate Cox models including both pediatric and adult patients confirmed that HLA mismatching had an initially protective effect at young ages (HR, 0.85; 95% CI, 0.73-0.99; P = .044) and that this protective effect diminished at older ages and was no longer associated with survival at P < .05 beyond age 10 years. CONCLUSIONS HLA mismatching has significantly different implications for survival after LTx in adult compared with pediatric patients with CF.
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Affiliation(s)
- Don Hayes
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio; Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio.
| | - Jeffery J Auletta
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; Host Defense Program, Nationwide Children's Hospital, Columbus, Ohio; Section of Hematology/Oncology and Bone Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio; Section of Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Bryan A Whitson
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Sylvester M Black
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Stephen Kirkby
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio; Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Heidi M Mansour
- Skaggs Pharmaceutical Sciences Center, The University of Arizona College of Pharmacy, Tucson, Ariz
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